Urology

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Kidney removal via lumbar access, eventually with the ureter

What does this procedure entail?

The procedure removes the kidney with decreased or no function causing various complications (inflammation, pain, hypertension, bleeding into the urinary tract), which may annoy the patient, but also pose a risk to their health or life. The procedure may be indicated in case of cancer of the mucous membrane of the urinary tract in the area of the kidney and ureter. The removal of the entire ureter, including its ending in the bladder, is indicated in this and several further cases.

What are the alternatives to this procedure?

Laparoscopic surgery
Observation – monitoring; only if the kidney disease is not probable to affect the patient's survival or the patient's medical condition does not allow for any other therapy;
In case of a tumour, also
Local treatment of the tumour itself (e.g. endoscopic) – only in certain indications
Systemic chemotherapy, biological treatment – in case of generalisation and metastases (spread to distant parts of the body via blood)

What should I expect before this procedure?

If you regularly use Anopyrin, Clopidogrel, Warfarin, etc., you must tell your doctor. These medications can be associated with increased risk of bleeding during and after the surgery if they are not stopped in time. In some cases, it is necessary to replace these drugs with injection preparations. It is necessary to consult your general practitioner or cardiologist about this approach.

At the request of the referring physician, you will have to schedule preoperative examinations to assess your overall condition, including laboratory and instrumental tests. If the report does not preclude the indicated procedure, you will be admitted to the hospital. If you don’t undergo a preoperative examination or it is incomplete, you will not be able to have the surgery as scheduled. You will be admitted by a nurse and a member of the medical team will complete your examination and assess your fitness for the surgery.

You will be asked not to eat or drink for at least 6 hours before the surgery!

In the evening before the surgery, you will receive medication from an anaesthesiologist to calm you down so that you sleep well.
Remember to inform your physician about the following possible facts before the surgery:

artificial heart valve
coronary artery stent
pacemaker
artificial joint
artificial vascular graft
neurosurgical bypass
other implanted foreign body
use of the following prescription drugs: Acylpyrin, Anopyrin, Aspirin, Godasal, Clopidogrel, Plavix, Kardegic, Aspegic, Micristin, Ibustrin,Ticlid, Tagren, Ipaton  Apo-Tic, Plavix, Persantin, Curantyl, Anturan, Aggrenox, Vessel due F.
drug and other allergies
any abnormalities or eventualities

It is NECESSARY to inform the physician about your use of drugs affecting blood clotting before your admission for the procedure.

What will happen during the surgery?

You will normally receive an injection or oral antibiotics before the procedure, but any allergies must be checked first.

The procedure is performed exclusively under general anaesthesia.

The surgery is performed from an incision in the lumbar region. The whole kidney is removed, including its surrounding structures (fibrous capsule, fat) after previous preparation and separation from the vessels and after the interruption of the ureter. A urinary catheter is inserted into the bladder before the surgery (it is used to collect urine). A drain is inserted into the kidney bed and possibly to the urinary bladder through the skin (it removes blood and tissue secretion from the original kidney location).

If it is necessary to remove the kidney with the entire ureter, the procedure is combined with the separation of the ureter from the bladder wall and its occlusion/closing. This part of the surgery is performed using a telescopic instrument inserted through the urethra. The catheter is left in the bladder for 7 days (spontaneous healing of the location where the ureter used to be). The ureter is then removed as a whole with the kidney.

It is sometimes necessary to separate the ureter from the bladder via the classic approach (not endoscopic) from an auxiliary incision in the lower abdomen.

The surgery takes about 60-120 minutes.

What will happen immediately after the procedure?

You will wake up at the intensive care unit equipped for continued monitoring of patients immediately after the procedure. The surgeon will inform you about the course of the procedure. You will still have high levels of anaesthetics in your blood at that time, so you may not remember this conversation.

Patients usually have an infusion access point inserted into a vein in their arm (usually right arm); if necessary, a monitoring/infusion port (a tube inserted into the vein to monitor blood pressure or administer drugs and nutrition) will be inserted into a vein (jugular vein) in the superclavicular region (the area between the collarbone and neck).

Nutrition is provided in an intravenous manner shortly after the surgery. You will receive a liquid and mushy diet for the next 2 to 3 days. This procedure is necessary for the proper restoration of gastrointestinal function. Non-compliance of the patient is usually associated with severe abdominal pain, vomiting with the risk of suffocation and may require surgical revision (further surgery in case of complications).

Physical rehabilitation is very important to prevent complications in the postoperative period. You will first exercise on the bed. As soon as your medical condition allows, you will be allowed to sit down and then stand up. After that, you will be able to walk slowly and carefully around the room, initially accompanied by medical staff. Pay close attention to your breathing, eventual dizziness, uncontrollable weakness, and to gait stability. Otherwise immediately inform medical personnel or anyone in the vicinity.

Sutures will be removed before you are discharged from the hospital. The average hospitalisation is 8-11 days.

Once you are fully conscious, you should:

ask if the planned outcome was achieved
inform the medical staff about any problems
ask what you can and cannot do
ask all the questions you have for the healthcare professionals and members of the medical team.
remember (and understand) why the surgery was performed, how it turned out, and what will follow

What are the postoperative risks or complications?

Common (10% of procedures of this type)

Bulging at the incision site due to damage to the nerves of the abdominal wall (interruption of muscle innervation when approaching the kidney)
Regular examination of the bladder (cystoscopy) during follow-up examinations (in case of cancer)

Rare (2-10% of procedures of this type) Bleeding requiring further surgery or transfusion

Lung injury requiring temporary removal of gas from the chest cavity
Need for further cancer treatment after the surgery
Infections, pain or swelling at the incision site requiring further treatment

Rare (may occur in 2% of procedures of this type)

Cardiovascular or anaesthesia-related complications that may require a longer stay at the intensive care unit (lung infections, pulmonary embolism, heart attack, deep vein thrombosis, etc.)
Injuries to nearby surrounding structures (blood vessels, spleen, liver, lungs, pancreas and intestines) requiring more extensive surgery or planned revision.
Unexpected histological results, e.g., the removed tumour was not malignant or was of a different type.
Urinary bladder fistula with urine leakage requiring prolonged catheterisation or further surgery.

Hospital infections

MRSA colonisation (0.9% – 1 of 110)
Intestinal infection by clostridium difficile (0.01% – 1 of 10,000)
MRSA blood infection (0.02% – 1 of 5,000)

Hospital infection rates may be higher in high-risk patients, such as in cases requiring long-term drainage, after a previous infection, after prolonged hospitalisation or after multiple hospitalisations.

What should I expect when I return home?

When you are discharged from the hospital, you should:

get recommendations on recovery at home
ask when you can return to normal activities such as work, exercise, driving, housework
get a contact number for further questions after returning home or in case of trouble</li>
ask about the date of the following check-ups and the place where you should come (hospital or your attending physician)
make sure you are aware of the reason, course and outcome of the surgery, the results of examinations or the removal of tissues or organs.

At your departure from the hospital (sometimes several days later), you will receive a hospitalisation report. The document contains important information about your hospital stay, your surgery and recommended follow-up. If you need to call your attending physician or visit the hospital for any reason, take this document with you so that the physician knows the details of your treatment. This is especially important if you need to consult another doctor or longer after discharge.

What else should I watch out for?

It is recommended that you wear elastic stockings for 2-3 weeks after the discharge from the hospital.

Uncomplicated skin incisions will heal in about 14 days. After that, you will be able to take a regular shower. The healing of internal structures takes 6 to 12 weeks, so it is necessary to maintain a resting regime even after discharge from the hospital. It usually takes 8-16 weeks until you are able to return to work. Talk about this with the doctor who treated you in the hospital, or at least with your general practitioner.

Many patients complain about persistent episodes of pain (pulling, pressure, pulsing) in the lumbar region, which can last for several months. If the kidney access incision is in the lumbar region, the wound may arch due to the interruption of the nerves supplying the muscles of the abdominal cavity – it is not a hernia. This condition can be improved by strengthening the muscles of the abdominal wall with exercise (only after full healing!).

Important information?

In case of fever, redness, pulsation or secretion at the site of the surgical wound, contact your attending physician. Inform your attending physician of any other problems related to the procedure, do not underestimate any breathing difficulties. Bulging in the area of the wound in the lumbar region due to interruption of the nerves supplying the abdominal muscles is not a reason for acute examination.

The results of the histological examination are usually available within 2-3 weeks after the surgery. These findings may be decisive for your further treatment. The date and place of your postoperative check-up will be determined at discharge based on the course of the surgery and postoperative care (usually 6-8 weeks after the surgery).

In case of cancer of the urinary tract, further monitoring at an outpatient urology or oncology office will be necessary (prevention or early detection of tumour recurrence).